Kyriacou D N, Ricketts V, Dyne P L, McCollough M D, Talan D A
Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, USA.
Ann Emerg Med. 1999 Sep;34(3):326-35. doi: 10.1016/s0196-0644(99)70126-5.
We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician.
Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies.
Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033).
Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.
我们对急诊科患者护理效率进行了为期5年的时间研究分析。我们的具体目标是：（1）计算急诊科患者护理的主要时间间隔，以确定效率低下的领域；（2）衡量急诊科和住院床位可用性对患者流程的影响；（3）定量评估旨在提高效率的行政干预措施的效果；（4）评估看医生等待时间与未被医生诊治即离开（LWBS）的患者数量之间的关系。
从1993年9月至1998年7月，采用相同的研究设计和方法进行了7次为期1周的急诊科患者流程时间研究。纳入主诉胸痛、腹痛、阴道出血和肢体损伤的患者，以代表我们洛杉矶县医院急诊科所见患者病情的严重程度。计算出代表评估和治疗主要阶段的时间间隔为：（1）分诊至登记完成；（2）登记完成至进入急诊科治疗区域；（3）进入急诊科治疗区域至初始医学评估；（4）分诊至初始医学评估；（5）初始医学评估至处置医嘱；（6）处置医嘱至患者从急诊科出院。还计算了急诊科总住院时间（LOS）作为效率的总体衡量指标。根据急诊科和医院住院床位的可用性比较时间间隔。评估行政干预对特定时间间隔的影响。评估看医生的中位等待时间与LWBS患者数量之间的关系。行政干预由一个跨部门的特殊持续质量改进委员会实施。干预措施针对时间研究确定的特定延误和效率低下来源。
7次时间研究共纳入826例患者。急诊科和住院床位不可用与显著延误相关。在前5个阶段，急诊科总住院时间的中位数从6.8小时显著减少至4.6小时，这可能是行政干预的结果。然而，在最后2个阶段，急诊科总住院时间的中位数从4.6小时增加至6.0小时，这可能是由于我们急诊科患者普查增加以及近期洛杉矶县财政危机导致护理和医生人员配备减少所致。LWBS患者数量与看医生的等待时间密切相关（r = 0.79，β = 5.20，P = 0.033）。
时间研究是识别患者护理延误领域的有效方法。在我们的急诊科，有针对性的行政干预措施明显减少了急诊科总住院时间并提高了整体效率。尽管急诊科住院时间最初有所下降，但效率似乎受到护理和医生人员配备减少以及患者普查增加的不利影响。看医生等待时间与LWBS患者数量之间关系的强度表明，减少等待时间可能会减少LWBS患者的数量。
